Lavage and the GI bleed

[olddog1]

Does anyone know the current thinking on "lavage til clear" for an upper GI bleed? Is this still recommended; does it actually work; aren't there more current and effective therapies.

[rjflyn, ASN, RN]

I hate lavage until clear. If someone is actively bleeding they are not going to "clear". Fortunately our GI doctors typically get them on the octreotide and protonix gtts and then come socpe the guys.

More often than not the NGT lavage till clear is an ER doc order to check to see if the pt really is bleeding from above. We also use it for those pts who you have not seen vomit that claim to be vomiting blood or who have black stools to check for UGI bleeding.

rj

[scattycarrot, BSN, RN]

This is interesting. I have worked in 3 different ER's in the UK and I have never lavaged till clear with an acute GI bleed. Priority has been resus and stablise, PPIs, treat any coag problems and transfer asap for urgent endoscopy. I know the GI docs where I last worked were adamant about not lavaging because of the risk of disturbing any clots that might be forming or have formed and particlarly, for fear of clipping a varices.

I don't know what the treatment is for the rest of the UK, so I dont know if this is a national standard.

[core0]

This is interesting. I have worked in 3 different ER's in the UK and I have never lavaged till clear with an acute GI bleed. Priority has been resus and stablise, PPIs, treat any coag problems and transfer asap for urgent endoscopy. I know the GI docs where I last worked were adamant about not lavaging because of the risk of disturbing any clots that might be forming or have formed and particlarly, for fear of clipping a varices.

I don't know what the treatment is for the rest of the UK, so I dont know if this is a national standard.

I would agree. There is really very little research on this.

I would look at it as what is the utility. Lets say someone comes in and said they had coffee ground emesis. You do the lavage and its positive. The result is an EGD. You do the lavage and its negative. The result is an EGD. It doesn't change your management. There is some thought that you could dislodge a clot and turn it into a problem. Also in patients with liver disease there is some thought that the NG tube could perforate a varix. This is probably more theoretical than real. In reality as a diagnostic test, it doesn't change management. The utility of a therapeutic lavage really hasn't been proven. The one trial of ice water lavages ended up pretty disastrously for the patients. Resuscitation and Protonix drip. EGD when stable in the ICU is what we usually do.

The one place it can be helpful is when you aren't sure where the bleeding is. Sometime hematochezia can be from an UGI bleed. In this case a diagnostic lavage would help determine where to start.

David Carpenter, PA-C

[ZippyGBR, BSN, RN]

This is interesting. I have worked in 3 different ER's in the UK and I have never lavaged till clear with an acute GI bleed. Priority has been resus and stablise, PPIs, treat any coag problems and transfer asap for urgent endoscopy. I know the GI docs where I last worked were adamant about not lavaging because of the risk of disturbing any clots that might be forming or have formed and particlarly, for fear of clipping a varices.

I don't know what the treatment is for the rest of the UK, so I dont know if this is a national standard.

as someone who works in an Acute Assessment Unit ( who take more than our fair share share of GI bleeds becasue one of the three hospitals n the trust doesn't have OOH scoping and doesn't do any emergent surgery) in the UK and has several years Emergencney dept experience in the UK ... i'd agree with scatty carrot , lavaging has the potnetial to hasten the demise of the patient by preventing a bleed from clotting adequately the UK standard of care seem to be resuscitate, IV PPI and then ASAP scope / theatre if fit for sedation/GA otherwise p continued resuscitation until fit / point of futility reached

[olddog1]

Thanks to all for your responses. My patient was 104 (yes that is correct) and had vomited coffee ground emesis x1- she came in with it on her gown. I felt like I was torturing her for no good reason because, as was stated by others, it wasn't going to change what we did for her and was more likely to cause harm. She had all the other treatments started 2 hrs before the doctor saw her/ I took over her care and hadn't vomited/had stable vs during that time.

I love octreotide but have found my ED docs don't use it because they don't know about it (that's for another post!) and are reluctant to use something new.

[core0]

Thanks to all for your responses. My patient was 104 (yes that is correct) and had vomited coffee ground emesis x1- she came in with it on her gown. I felt like I was torturing her for no good reason because, as was stated by others, it wasn't going to change what we did for her and was more likely to cause harm. She had all the other treatments started 2 hrs before the doctor saw her/ I took over her care and hadn't vomited/had stable vs during that time.

I love octreotide but have found my ED docs don't use it because they don't know about it (that's for another post!) and are reluctant to use something new.

For most GI bleeds (ie ulcer related) Octreotide really doesn't have a role. The key is getting lots of a PPI on board. If you can keep the pH above six it dramatically enhances clot stability.

On a 104 year old I think that you are exactly right. I would be very hesitant on endoscopy. If its an ulcer and the crit is stable on a PPI then send her out on BID PPI. Besides ulcer the other things you are looking for (ie esophageal or gastric cancer) aren't really amenable to treatment in a 104 year old.

David Carpenter, PA-C

[yourbeautiful1028, RN]

hello just read all your messages..wanna ask how do you do "lavage until clear"? using IV fluid or sterile water...thanks